I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a resident is receiving services from a behavioral health residential facility's employee or personnel member, the administrator shall: 1. If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation; 2. Report the suspected abuse, neglect, or exploitation of the resident: a. For a resident 18 years of age or older, according to A.R.S. § 46-454; or b. For a resident under 18 years of age, according to A.R.S. § 13-3620; 3. Document: a. The suspected abuse, neglect, or exploitation; b. Any action taken according to subsection (I)(1); and c. The report in subsection (I)(2); 4. Maintain the documentation in subsection (I)(3) for at least 12 months after the date of the report in subsection (I)(2); 5. Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (I)(2): a. The dates, times, and description of the suspected abuse, neglect, or exploitation; b. A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident ' s physical, cognitive, functional, or emotional condition; c. The names of witnesses to the suspected abuse, neglect, or exploitation; and d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and 6. Maintain a copy of the documented information required in subsection (I)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.
Based on documentation review, record review, and interview, the administrator failed to ensure if an administrator had a reasonable basis, according to A.R.S. \'a7 13-3620 or 46- 454, to believe abuse, neglect, or exploitation occurred on the premises or while a resident was receiving services from a behavioral health residential facility's employee or personnel member, the administrator reported, documented, and initiated an investigation of the suspected abuse. The deficient practice posed a risk to resident safety as E2 failed to report the incident that occurred on April 4, 2024, involving R1.
A.R.S. \'a7 13-3620(A) states any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature or who reasonably believes there has been a denial or deprivation of necessary medical treatment or surgical care or nourishment with the intent to cause or allow the death of an infant who is protected under section 36-2281 shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety. 1. A review of the facility's policies and procedures dated in 2023, stated "All employees and volunteers will immediately report to the facility administrator any suspected abuse, neglect, or exploitation of the resident. If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was accepted or while the resident is not on the premises and not receiving services from the facility, the administrator shall immediately report or cause reports to be made to a peace officer or to a protective services worker and report to the legal guardian if resident has one. The above reports shall be made immediately in person or by telephone and shall be followed by a written report mailed or delivered within forty-eight hours or on the next working day if the forty- eight hours expire on a weekend or holiday." 2. In an interview, R1 reported R1 believed E2 had "elbowed" R1 on purpose. 3. A review of facility documentation revealed a witness statement from a school staff member dated May 5, 2024 from O2, which stated: "On April 5, 2024 at approximately 2:35 PM, an employee of the group home stopped abruptly at the security door of the school with [R1]. When [E2] stopped [E2] tensed [E2's] stance and extended [E2's] elbow, then proceeded to push [E2's] elbow into [R1's] torso. The employee [E2] and [R1] then both engaged in a verbal argument walking out the door. I then separated them both, keeping [R1] in the building while [E2] walked out... At the car, [R1] entered the vehicle and both [E2] and [R1] continued to engage verbally with each other. At one point, [E2] exited the driver's seat and postured up to [R1]. [R1] then exited the vehicle. As the vehicle moved through the roundabout in front of the office, [R1] opened the door to exit the vehicle. [E2] stopped the vehicle and [R1] exited.... During the incident that occurred on campus [officer] de-escalated [R1's] emotional reactive responses. When [E2] entered the room and spoke with [R1], [E2] argued with and, in my opinion, provoked [R1]." 4. In an interview, E1 was asked if E1 was made aware of the alleged incident between E2 and R1. E1 denied being aware of the incident that took place on April 5, 2024 between E2 and R1. E2 failed to report any incident to E1 until six days after. 5. In a telephonic interview, O1 reported the facility was called to pick up R1 as R1 had been disciplined for skipping class. When E2 arrived at the school to pick up R1, E2 was observed as being "antagonizing" towards R1. O1 reported both R1 and E2 were arguing back and forth with each other. O1 reported at one point E2 argued with R1 saying R1 would fail school for skipping class. R1 responded by commenting R1 would do better. However, O1 reported E2 responded by saying "You're just saying that, you're not going to do better." O1 reported when R1 and E2 got in the van to leave the school, R1 got out of the van as E2 was still arguing with R1. O1 however, was able to calm R1 down and decided to transport R1 back to the facility instead of having E2 transport R1 back to the facility. O1 described E2's behavior as unprofessional and unnecessary as it appeared E2 was trying to agitate R1 more than R1 was already agitated. O1 reported while walking out of the school, down the sidewalk, R1 was walking behind E2. "E2 stopped walking and stiffened his body, mostly E2's arm, stuck out his elbow and E2's elbow hit R1. When R1 stated that E2 elbowed R1, E2 denied elbowing R1 and said that if E2 did, it was not intentional. O1 reported O1's body camera was on. O1 stated that E2 did intentionally elbow R1. O1 reported there were no injuries, marks, or bruises observed. O1 reported R1 was becoming more annoyed. It was also observed that E2 took R1's backpack. When R1 asked E2 to give back the backpack, E2 told R1, "No, you're not getting it back. You don't own anything. Everything is mine." R1 stated that E2 always acts this way and stated "E2 also threatens that E2 is going to beat our butts or beat us up." 6. In an interview, R1 corroborated O1's account of the incident between R1 and E2. 7. In an interview, E2 reported E2 did not intentionally "elbow" R1 but rather felt R1 was "in E2's space" and used E2's elbow to create space between E2 and R1, which R1 ran into. 8. In an interview, E1 acknowledged the suspected abuse was not properly reported or investigated as per R9- 10-703.I.1-6 and according to the facility policies and procedures as E1 reported not being made aware of the incident by E2 until six days after the incident occurred. This is a repeat deficiency from an complaint investigation conducted on October 31, 2023. Plan of Correction Name, title and/or Position of the Person Responsible Date temporary correction was implemented Date permanent correction will be complete 2024-06-30 Temporary Solution Permanent Solution Monitoring